Provider Demographics
NPI:1790877413
Name:FOUNTAIN, VIVIAN MARIE (OD)
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:MARIE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:VIVIAN
Other - Middle Name:MARIE
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:130 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2443
Practice Address - Country:US
Practice Address - Phone:985-872-2020
Practice Address - Fax:985-872-2069
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS638152W00000X
MSMS 638152W00000X
LA1804-738AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS94199OtherTPA
MSMS 638OtherSTATE LICENSE
MSMS 638OtherSTATE LICENSE
MS79997Medicare UPIN